Performance measurement in healthcare was introduced in response to evidence of wide variations in practices among physicians, inappropriate care, and high rates of people not receiving treatments known by professional organizations and guidelines to be effective. Since the performance measurement trend began, programs such as National Committee for Quality Assurance's (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) have stimulated increases in the use of evidence-based treatments. It is estimated that related improvements in performance are estimated to have prevented 1,900,000 heart attacks, 800,000 strokes, and 100,000 cases of end-stage renal disease in the first ten years of HEDIS.
However, the role of performance measurement is not limited to measuring quality. For example, performance measurement is increasingly used in “pay for performance” incentive programs for healthcare professionals. In such programs, the bonus earned by a physician may be partially or entirely based on metrics associated with a particular performance metric system.
Most methods of measuring performance are based on guidelines. For example, the HEDIS blood pressure measure, which counts the proportion of people with a diagnosis of hypertension who have systolic blood pressure (SBP) controlled to less than 140, is based directly on the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC 7) guideline. When relying on guidelines such as the JNC 7 guideline, performance measures inherit the evidence that supports the guideline. This helps insure that improvements in performance on these measures will improve health outcomes. Furthermore, aligning performance measures to guidelines insures that physicians get consistent messages; they are not asked to do one thing by a guideline while their performance is measured against a different standard.
Guidelines focus on actions providers should take and how they should perform them. However, measures based on processes and treatment targets carry no information about the effects on health outcomes, do not permit comparisons of different measures, and provide no incentives to find the most effective and efficient ways to improve outcomes.
Performance measures based on guidelines also have the effect of turning guidelines into rules. Often, providers are penalized if they do not adhere to the measure, even in cases when the measure calls for an action that is inappropriate or unnecessary, and providers get no credit if go beyond the immediate target of a measure. Basing performance measures on particular guidelines tends to deemphasize other guidelines. There is no penalty if providers ignore guidelines for which there are no corresponding performance measures, and if the provider achieves the target of the measure he has delivered high quality care and can therefore cease care. Further, there is an incentive to preferentially allocate resources towards guidelines for which there are performance measures, and away from guidelines for which there are not.
Guidelines are issued in isolation of one another, since guidelines are designed by groups that have the greatest interest and expertise. As a result, there is no process for making comparisons across measures and no way to determine their relative importance. Further, giving each performance measure equal weight often leads to misplaced priorities. For example, one part of the third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) recommendation, referred to herein as “ATP III” recommends controlling LDL cholesterol to below 100 mg/dL in people with cardiovascular disease (CVD), which reduces the patient's 30-year risk of a MI by about 39%. But controlling LDL cholesterol to below 160 mg/dL in people with fewer than two risk factors, as recommended by another part of the ATP III recommendation, reduces the patient's 30-year risk of a MI by about 5%. These two parts of the ATP III guideline not only have dramatically different impacts on the patient's risk, but they also have very different costs. Giving these two recommendations the same emphasis leads to inefficient use of resources and misplaced attention.
Most guidelines are clinically simplistic and tend to focus on one factor at a time, such as a patient's blood pressure. Guidelines also tend to use sharp cut-off points to separate those who should be treated from those who should not. An example of this is a hypertension guideline recommending that blood pressure be controlled to less than 140/90 mm Hg. These simplifications make guidelines easier for physicians to remember and patients to understand, but this simplicity can harm the quality and efficiency of care by encouraging the treatment of the wrong people.
Although performance measurement has undeniably improved the quality of care provided to patients, current methods of measuring performance do not go far enough.
The approaches described in this section are approaches that could be pursued, but not necessarily approaches that have been previously conceived or pursued. Therefore, unless otherwise indicated, it should not be assumed that any of the approaches described in this section qualify as prior art merely by virtue of their inclusion in this section.